Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Stimulant-Related Disorders (Amphetamine-Type Substance)


Related Terms

  • Addiction to Dexedrine
  • Addiction to Preludin
  • Addiction to Ritalin
  • Amphetamine Addiction
  • Chalk Addiction
  • Crystal Addiction
  • Glass Addiction
  • Ice Addiction
  • Meth Addiction
  • Methamphetamine Addiction
  • Speed Addiction

Differential Diagnosis

Specialists

  • Cardiovascular Internist
  • Clinical Psychologist
  • Neurologist
  • Occupational Therapist
  • Psychiatrist

Comorbid Conditions

  • Alcohol dependence
  • Hepatitis B or C
  • HIV/AIDS
  • Other psychiatric disorders (dual diagnosis)
  • Other substance disorders

Factors Influencing Duration

Length of disability is influenced by the duration and severity of amphetamine abuse, presence or absence of organ damage, any underlying mental illness, other substance abuse, motivation to change, the individual's social support system, appropriateness of treatment choice, compliance with treatment, and adequacy of ongoing care.

Medical Codes

ICD-9-CM:
304.40 - Amphetamine Dependence; Unspecified
304.41 - Amphetamine Dependence; Continuous
304.42 - Amphetamine Dependence; Episodic
305.70 - Amphetamine or Related Acting Sympathomimetic Abuse; Unspecified
305.71 - Amphetamine or Related Acting Sympathomimetic Abuse; Continuous
305.72 - Amphetamine or Related Acting Sympathomimetic Abuse; Episodic

Overview

Amphetamines are potent central nervous system stimulants and include drugs such as amphetamine, dextroamphetamine, methamphetamine (speed), and various appetite suppressants and decongestants. Although it is a central nervous system stimulant, methylphenidate (Ritalin) is chemically different from a true amphetamine; it is less potent than most amphetamines but more potent than caffeine.

Amphetamine use releases the brain chemical dopamine, which stimulates brain cells, enhancing mood and movement. It may also damage brain cells that contain dopamine and another nerve chemical (neurotransmitter) called serotonin. Over time, levels of dopamine decrease. This may cause stiffness, tremor, and other symptoms similar to those in Parkinson's disease.

As with any addiction process, abuse and dependence are defined by continued use in the face of negative consequences. These consequences may fall into one or more of the following areas: physical and psychological health, occupational functioning, legal problems, interpersonal relationships, and financial affairs. A useful definition of dependence is loss of control over when and how much of the substance is used. The diagnosis of abuse is made when the use of the substance is recurrent despite adverse consequences to the person. The diagnosis of amphetamine abuse and dependence is based on criteria listed in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR).

These substances can be taken orally, inhaled through the nose, smoked, or injected intravenously. The effects may appear in 30 to 40 minutes and last for 4 to 8 hours. Amphetamine use may result in feelings of being high or elated (euphoria), talkativeness, hyperactivity, restlessness, heightened awareness of threatening or other stimuli (hypervigilance), anxiety, tension, grandiosity, anger, and impaired judgment. Other effects may include decreased appetite, more rapid breathing (tachypnea), increased heart rate (tachycardia) and blood pressure (hypertension), fever (hyperthermia), confusion, tremors, seizures, suspiciousness (paranoia), and aggressive behavior.

Many individuals begin use of amphetamines to lose weight, while others use amphetamines for some types of inadvertent self-medication or for recreational purposes; some students use amphetamines as a study aid. MDMA, a methamphetamine-based recreational stimulant popularly called ecstasy (the most potent form of methamphetamine), generates effects lasting 3 to 6 hours. MDMA is often used as a "club drug" by dancers seeking the sense of rapture, excitement, and social dis-inhibition it produces.

Smoked or injected amphetamine more commonly leads to dependence than does the oral form. Individuals who have used daily for 8 to 10 years tend to decrease or stop use because of adverse side effects such as depression, sleep disturbances, malnutrition, or cardiovascular complications, including chronic chest pain or irregular heart rate.

As methamphetamine can be easily manufactured illegally from store-bought materials, it is the most prevalent synthetic drug manufactured in the US.

Note: For the substance/medication-induced disorders approach established by the DSM-IV-TR, and the DSM-5, please see the following topics: Substance/Medication-Induced Anxiety Disorder, Substance/Medication-Induced Bipolar and Related Disorder, Substance/Medication-Induced Depressive Disorder, Substance/Medication-Induced Major or Mild Neurocognitive Disorder, Substance/Medication-Induced Obsessive-Compulsive and Related Disorder, Substance/Medication-Induced Psychotic Disorder, Substance/Medication-Induced Sexual Dysfunction, and Substance/Medication-Induced Sleep Disorder.

Incidence and Prevalence: The initiation of MDMA use in the US has been rising steadily since 1992, with 1.8 million new users in 2001. The number of users in 2002 was estimated to be 676,000. In 2004, more than 11 million people had tried MDMA at least once in their lifetime (Volkow), an increase from the 6.4 million reporting use in 2000.

According to the DSM-5, the estimated 12-month prevalence of amphetamine-type stimulant use disorder in the US is 0.2% among individuals 12 years and older. Rates are similar among adults of both sexes (0.2%); however, among 12- to 17-year-olds, the rate is greater for females (0.3%) than for males (0.1%). Intravenous stimulant use is greater among males (male-to-female ratio of 3:1 or 4:1), but rates are more balanced among non-injecting users (males represent 54% of primary treatment admissions). Twelve-month prevalence is greater among younger individuals. For 12- to 17-year-olds, rates are highest among whites and African Americans (0.3%), followed by Hispanics (0.1%) and Asian Americans and Pacific Islanders (0.01%); amphetamine-type stimulant use disorder is almost absent among Native Americans of this age. Among adults, rates are highest among Native Americans and Alaska Natives (0.6%), followed by whites (0.2%) and Hispanics (0.2%); amphetamine-type stimulant use disorder is almost absent among African Americans and Asian Americans and Pacific Islanders of this age. Past-year non-prescribed use of prescription stimulants occurred among 5%-9% of children through high school; 5%-35% of college-age persons report past-year use.

Source: Medical Disability Advisor



Causation and Known Risk Factors

Amphetamine use is most prevalent from ages 18 to 30 (16% in one survey). Intravenous use is more common in lower socio-economic groups and is 3 to 4 times more common in men than women. Approximately equal numbers of men and women use amphetamines by other routes. Use of these agents is associated with an increased risk of heart attack, irregular heart rhythms, and stroke.

In 1997, there were more than 50,000 hospital admissions in the US for treatment of methamphetamine abuse or its complications, accounting for almost 4% of all treatment admissions. There is higher use in some locales such as Southern California (DSM-IV-TR). A pattern of abuse may lead to fever and seizures which may result in death.

Source: Medical Disability Advisor



Diagnosis

History: The patterns of use and course of amphetamine dependence and cocaine dependence are similar because both are potent central nervous system stimulants and have similar psychoactive and sympathomimetic effects. However, amphetamines are usually self-administered fewer times per day because they are longer acting than cocaine. Usage of amphetamine may be chronic or episodic (like cocaine dependence), with binges ("speed runs") and brief drug-free periods. Amphetamine dependence is associated with aggressive or violent behavior, particularly with the use of high doses (smoked, ingested, or administered intravenously). As with cocaine, intense but temporary anxiety (resembling panic disorder or generalized anxiety disorder), as well as paranoid ideation and psychotic episodes (that resemble schizophrenia, paranoid type), are often seen, particularly in association with high-dose use.

Withdrawal states are often associated with temporary, but potentially intense, depressive symptoms (that can resemble a major depressive episode). Tolerance to amphetamines develops and often leads to escalation of the dose. Conversely, some individuals with amphetamine dependence develop sensitization (enhanced augmentation of an effect following repeated exposure), in which case small doses may produce marked stimulant and other adverse mental and neurological effects (DSM-IV-TR). Withdrawal usually consists of utter physical and mental exhaustion in the wake of sustained use (runs or binges of use may last for days to weeks, during which time the user sleeps infrequently, if at all).

The difference between abuse and dependence is usually one of degree. Because there may be no dramatic physical effects seen when the drug is withdrawn, a medical and behavioral history is very important in establishing the diagnosis of amphetamine abuse or dependence. The DSM-IV-TR focuses on the pattern of use of the amphetamine substances during the past 12 months. A noticeable drop in performance in work, school, or the home; recurrent use of the substance in hazardous situations; recurrent substance-related legal problems or persistent interpersonal or social problems either caused or worsened by use of the substance, such as arguments with a spouse, are sufficient for the diagnosis.

Psychosis, as reflected in disorganized, expansive, or formal thought dysfunctions, may be evident in association with prolonged and severe abuse. This often has the appearance of a paranoid form of psychosis that may be virtually indistinguishable from paranoid schizophrenia. This thought process is usually temporary and reverses within hours to days as the effects of the drug wear off. In rare cases, however, the symptoms may persist for months to years.

The guidelines for diagnosis are the same as many stimulant use disorders. Individuals have a problematic pattern of amphetamine use leading to clinically significant impairment or distress, as manifested by 2 or more (as specified in DSM-5) or at least 3 (as specified in the DSM-IV-TR) of the following, occurring within a one-year period:
• Stimulant is often taken in larger amounts or over a longer period than was intended.
• There is a persistent desire or failed efforts to reduce or control stimulant use.
• Much time is spent in activities necessary to obtain stimulant, use stimulant, or recover from its effects.
• There is craving (a strong desire or urge to use stimulant).
• There is recurrent stimulant use that results in a failure to fulfill major role obligations at work, school, or home.
• There is continued stimulant use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of stimulant.
• The individual gives up or reduces important social, occupational, or recreational activities because of stimulant use.
• There is recurrent stimulant use when it is physically hazardous.
• The individual continues stimulant use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the stimulant.
• There is tolerance (a need for markedly increased amounts of stimulant to achieve intoxication or desired effect, or a markedly diminished effect with continued use of the same amount of stimulant).
• There is withdrawal syndrome for the stimulant.
• The individual takes the stimulant (or a closely related substance) to relieve or avoid withdrawal symptoms.
It is necessary to specify the current severity: mild (presence of 2-3 symptoms), moderate (4-5 symptoms), or severe (6 or more symptoms) (DSM-5).

Withdrawal syndrome appears after cessation of amphetamine-type substance, cocaine, or other stimulant use, and consists of dysphoric mood and at least two of the following: fatigue; vivid, unpleasant dreams; insomnia or hypersomnia; increased appetite; and psychomotor retardation or agitation. The signs or symptoms develop within a few hours to several days after the cessation of amphetamine-type substance, cocaine, or other stimulant use; cause clinically significant distress or impairment in social, occupational, or other important areas of functioning; are not attributable to another medical condition; and are not better accounted for by another mental disorder, including intoxication or withdrawal from another substance (DSM-5).

Physical exam: Besides the psychological effects mentioned, the acute effects of amphetamines include a pronounced increase in sympathetic nervous system signs such as elevated heart rate (tachycardia), dilated pupils (mydriasis), elevated or lowered blood pressure (hypertension or hypotension), perspiration, nausea or vomiting, and psychomotor agitation or retardation, as well as muscular weakness, respiratory depression, chest pain, confusion, seizures, or coma. A common indicator of recent use is an excess of energy that expresses itself through constant movement. The user seems wired and hyperactive and may be extremely fidgety and restless or may repeat non-purposeful movements (motor overflow). Over time, these drugs may take a major toll on physical health. One of the more obvious signs is weight loss. If the drugs are used intravenously, needle tracks may be visible.

Tests: Amphetamines are rapidly metabolized and eliminated and urine tests remain positive for only 1 to 3 days. Some laboratories now have the technology for testing hair samples for amphetamines and other drugs of abuse. Hair testing offers the advantage of longer detection times than are usually obtained with urine analysis. If there are abnormalities of heart rhythm or rate, electrocardiogram (ECG) may be warranted. Electroencephalogram (EEG) should be done if there is evidence of seizures or convulsions.

Note: It must be kept in mind that just because a physical diagnosis cannot be established as the cause of the presenting symptomatology, it does not necessarily mean that the cause is a mental one. That is to say that the presence of medically unexplained symptomatology does not necessarily establish the presence of a psychiatric condition. The first step in identifying the presence of a mental disorder is excluding the presence of malingering and/or of factitious disorder. Although factitious disorder is conscious and purposeful, it is classified as a psychiatric disorder. The strong need for this step is especially true whenever there is a medicolegal context associated with the presenting problem(s). Additionally, using DSM-5 and/or ICD-9-CM or ICD-10-CM, the clinician will find that many presentations fail to fit completely within the boundaries of a single mental disorder. There are systematic ways to go about making psychiatric diagnoses, however.

Source: Medical Disability Advisor



Treatment

The treatment goal with amphetamine abuse and/or dependence/stimulant use disorder is for the patient to achieve abstinence. Fatigue, restlessness, and depression may occur several days after the start of the withdrawal process. Although antidepressant medications can be helpful in combating depressive symptoms, severely depressed individuals may become suicidal during withdrawal. For this reason, chronic users may need to be hospitalized during drug withdrawal. Individuals who experience delusions or hallucinations may require the use of antipsychotic medications, such as haloperidol or chlorpromazine, to calm and relieve distress. Individuals in this condition often benefit from psychiatric hospitalization. Currently, there is no known medication for the successful long-term treatment of amphetamine dependence itself.

In general, amphetamine recovery occurs in four phases. The acute phase of treatment focuses on alleviating symptoms of physiological withdrawal and typically lasts 3 to 5 days. The next phase is a 1-month period of abstinence during which the individual focuses on changing his or her behaviors. The early remission phase can last up to 12 months. The sustained remission phase lasts as long as the individual abstains from amphetamine use.

The most effective treatments for amphetamine dependence/stimulant use disorder are cognitive behavioral therapy and addiction education and support groups. Narcotics Anonymous is a widely used and beneficial adjunct in the long-term recovery from these drugs. These interventions are designed to help modify the individual's thinking, expectancies, and behaviors and to increase coping skills for various life stressors. Other ongoing structured self-help programs such as Alcoholics Anonymous, and Rational Recovery are recommended as an adjunct to treatment services. Early treatment usually occurs in an outpatient setting and may include education on physical, emotional, and mental aspects of addiction and recovery; identification of stressors and stress management skills; improved coping skills; assertiveness training; relaxation training; and individual or family psychotherapy. Regular but random drug screens may be part of the treatment process.

Individuals should understand that relapse may occur and is often even part of the recovery process. Medication therapy may include dopamine antagonists and/or antidepressants as indicated by psychiatric or clinical evaluation. Inpatient substance abuse treatment is needed for severe depression or psychotic symptoms lasting beyond 1 to 3 days after abstinence; for repeated outpatient failures; or if the individual is violent toward others, suicidal, or has severe withdrawal symptoms during detoxification.

Source: Medical Disability Advisor



Prognosis

Some individuals respond to treatment and stay in remission from substance abuse for many years. However, some individuals experience periods of relapse where they begin using amphetamines after a period of remission and again meet the criteria for substance abuse. Other individuals are never able to abstain from substance use/abuse and do not experience any periods of remission. Individuals who develop new relationships and consistently make use of self-help groups are more likely to experience continued abstinence and achieve improvement in social and occupational functioning. Most experts agree that addicts need to do more than just kick their habits. They need to make life changes and find meaning and motivation to move ahead.

Specific outcomes associated with amphetamine abuse may include weight loss and malnutrition, paranoid psychosis, brain damage, seizures, and heart disease. There is little reliable national information on the long-term prognosis for individuals using amphetamines on a chronic basis. Smaller studies provide some information. In 2002, the University of Florida reported a study of 1,304 overdose deaths from recreational drugs occurring in 2001. Of those, 621 of the deaths involved multiple drugs and 31 of those involved methamphetamine. The mortality rate associated with amphetamine abuse is thought to be increasing.

Source: Medical Disability Advisor



Complications

Other psychiatric illnesses may be present and complicate treatment of both the amphetamine dependence/stimulant use disorder and the other illness (dual diagnosis). About half of those with bipolar mood (affective) disorder or schizophrenia may have drug or alcohol problems. Those with post-traumatic stress disorder may have substance abuse rates as high as 80%. with prolonged use, an individual may experience depression, weight loss with malnutrition, or impaired personal hygiene. Intravenous use may lead to skin infections, bacterial endocarditis, HIV, or hepatitis. Complications of amphetamine abuse may include weight loss and malnutrition, heart disease, or seizures. Brain damage from methamphetamine use can be similar to that caused by Alzheimer's disease, Parkinson's disease, stroke, or epilepsy.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

State and federal statutes may require accommodations for employees with amphetamine dependence/stimulant use disorder, and have strict guidelines for protecting the rights of affected employees to confidential handling of their medical findings and health status. Many employers have systems in place for individuals recovering from substance abuse disorders that allow them to return to work under special contracts or conditions. These conditions usually include routine or random testing of blood and urine levels for identified substances, and work performance and substance abuse treatment guidelines for the recovering individual. Individuals should not work at all if intoxicated.

Temporary work accommodations may include reducing or eliminating activities where the safety of self or others is contingent upon a constant and/or high level of alertness, such as driving motor vehicles, operating complex machinery, or handling dangerous chemicals; introducing the individual to new or stressful situations gradually under individually appropriate supervision; allowing some flexibility in scheduling to attend therapy appointments (which normally should occur during employee's personal time); promoting planned, proactive management of identified problem areas; and offering timely feedback on job performance issues. It will be helpful if accommodations are documented in a written plan designed to promote a timely and safe transition back to full work productivity.

After detoxification, if the individual has chronic medical conditions resulting from prolonged substance abuse, such as cardiac, liver, or nervous system damage, restriction to sedentary activities at work may be necessary. Employment in areas where there is ready access to addictive substances (e.g., pharmacies or establishments that serve liquor) is contraindicated.

Source: Medical Disability Advisor



Maximum Medical Improvement

MMI is expected at 6 months of treatment or less.

Note: MMI is estimated under the assumption that the vagaries involved in psychiatric diagnoses have been taken into consideration.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Does individual continue to use amphetamines despite the consequences?
  • Does individual exhibit at least 3 psychological symptoms of amphetamine dependence or abuse, or at least 2 of stimulant use disorder?
  • Does individual display any physical symptoms of amphetamine use?
  • Were conditions with similar symptoms ruled out?
  • Were all underlying medical and psychiatric disorders identified?

Regarding treatment:

  • Is individual involved in a cognitive behavioral therapy program that helps modify individual's thinking, expectancies, and behaviors? Does this therapy program help increase individual's coping skills for various life stressors?
  • Is individual participating in a substance recovery support group?
  • If individual exhibits severe depression or suicidal tendencies, would he or she benefit from antidepressant medication or hospitalization until stabilized?
  • If individual is experiencing psychotic symptoms, such as delusions or hallucinations, would individual benefit from antipsychotic drug therapy or psychiatric hospitalization?

Regarding prognosis:

  • At what point of treatment is individual currently?
  • Is he or she experiencing relapses? Are relapses decreasing in frequency?
  • Would individual benefit from more frequent, more intense, or longer treatment?
  • Does individual require external support and motivation to continue in treatment beyond the initial stage of detoxification?
  • Does individual participate in a formal support group?
  • What other support systems does individual have in place?
  • Is individual able to develop new relationships?
  • Is improvement evident in social and occupational functioning?
  • Is individual receiving the necessary tools, skills, and encouragement to move ahead with his or her life?

Source: Medical Disability Advisor



References

Cited

Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th ed. American Psychiatric Association, 2013.

Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). 4th ed. Washington, DC: American Psychiatric Association, 2000.

Volkow, Nora D. "Letter from the Director." National Institute on Drug Abuse. Mar. 2006. National Institutes of Health (NIH). 24 Apr. 2015 <http://www.drugabuse.gov/publications/research-reports/mdma-ecstasy-abuse/letter-director>.

Source: Medical Disability Advisor






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